Heel Pain

INTRODUCTION

Important causes of heel pain include:

• Achilles tendon disorders

  • – tendinopathy/peritendinitis

  • – bursitis

    • postcalcaneal

    • retrocalcaneal

  • – tendon tearing

    • partial

    • complete

• bruised heel

• tender heel pad—usually atrophy

• ‘pump bumps’

• plantar fasciitis

• calcaneal apophysitis

• peroneal tendon dislocation

• posterior tibialis tendinopathy

• tarsal tunnel syndrome

• neuropathies (e.g. diabetic, alcoholic)

US examination is useful to differentiate the causes of Achilles tendon disorders.

ACHILLES TENDON BURSITIS

Bursitis can occur at two sites:

• posterior and superficial—between skin and tendon

• deep (retrocalcaneal)—between calcaneus and tendon (see Fig. H9)

Treatment

• Avoid shoe pressure (e.g. wear sandals)

• 1–2 cm heel raise inside the shoe

• Apply local heat and ultrasound

• NSAIDs (14-d trial)

• Inject corticosteroid into bursa with a 25 g needle

PLANTAR FASCIITIS

This common condition (also known as ‘policeman’s heel’) is characterised by pain on the plantar aspect of the heel, esp. on the medial side; it usually occurs about 5 cm from the posterior end of the heel.

History

• Pain:

  • – under the heel

  • – first steps out of bed

  • – relieved after walking about

  • – increasing towards the end of the day

  • – worse after sitting

• May be bilateral—usually worse on one side

• Typically >40 yrs

• Both sexes

Signs

• Tenderness: deep and localised

• Heel pad may bulge or appear atrophic

• Crepitus may be felt

• No abnormality of gait, heel strike or foot alignment

Treatment

• Heals spontaneously in 12–24 mths

• Consider trial of NSAIDs—3 wks

• Therapeutic foot massages

• Exercise program to stretch Achilles tendon and plantar fascia (very effective)

• US therapy

• Hydrotherapy: place foot alternately 30 secs in hot and cold water for 15 mins

• Protect heel with an orthotic pad to include heel and foot arch (e.g. Rose insole or thick pad of sponge or sorbo rubber)

• Injection of LA and depot corticosteroid into tender site helps for at least 2–3 wks for very severe pain (otherwise avoid)

ACHILLES TENDINOPATHY/PERITENDINITIS

Clinical features

• History of unaccustomed running or long walk

• Usually young to middle-aged males

• Aching pain on using tendon

• Tendon feels stiff, esp. on rising

• Tender thickened tendon

• Palpable crepitus on movement of tendon

Treatment

• Rest: ?crutches in acute phase, plaster cast if severe

• Cool with ice in acute stage, then heat

• NSAIDs (14-d trial)

• 1–2 cm heel raise under the shoe

• US and deep friction massage

• Mobilisation, then graduated stretching exercises

Avoid corticosteroid injection in acute stages and never give into tendon. Can be injected around the tendon if localised and tender.